New Cochrane review highlights lack of evidence on medicine-taking ability and adherence in older adults

Interventions initiated at the hospital-community interface may be the best way to influence multiple medicine adherence in older adults, a new Cochrane review has found. 

The review, the largest ever to look at this cohort of patients, was conducted by researchers from Monash University’s Centre for Medicine Use and Safety.

Released earlier this month, the review included 50 relevant studies involving more than 14,000 participants aged 65 and older that tested interventions versus usual care. Six of the studies also compared two different types of interventions as part of a three-arm RCT design.

Due to the major differences in interventions received – including where they were delivered and how and when medicine-taking ability or adherence was measured – the quality of evidence produced by the studies was considered low or very low.

This meant the researchers were unable to conclusively determine the effect of interventions on medicine-taking ability.

However, based on low-quality evidence, they said behavioural-only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medicines. 

Mixed educational and behavioural interventions may also reduce the number of hospital admissions and may improve medicine knowledge, the researchers suggested.

A gap in the literature

Co-author Dr Amanda Cross MPS said the topic was one the researchers were passionate about, and which stemmed from their witnessing the non-adherence and poor medicine-taking ability among older adults while working as community, hospital and Home Medicines Review pharmacists. 

‘This was the first review of interventions to improve medicine-taking ability in older adults taking multiple medicines, and the largest, most comprehensive review of interventions to improve adherence in this population,’ Dr Cross told Australian Pharmacist.

Previous reviews had focused on adherence in younger adults, or adherence to single medicines or medicine classes, she said.

‘Interventions for younger people with simpler regimens may not translate to older people taking multiple medicines,’ Dr Cross said. 

‘Identifying the most effective interventions could help to improve medicine effectiveness and reduce adverse drug reactions.’

Dr Cross said she hoped the review would remind pharmacists that improving older patients’ adherence to multiple medicines was challenging and complex. It is also extremely important, as poor medicine-taking ability and non-adherence in older adults is linked to adverse medicine events, including hospitalisations, and poor quality of life.

‘While there is a growing amount of important research in the area of deprescribing, there is often a lack of focus on adherence and medicine-taking ability when polypharmacy is unavoidable,’ she said.

‘I hope that this review highlights this important area of clinical practice and stimulates further high-quality research in this area.’

Improving adherence

Pharmacists are uniquely placed to identify patients who are at risk of, or who are currently experiencing, non-adherence or poor medication-taking ability, Dr Cross said.

‘Pharmacists can identify these patients when dispensing medicines, when counselling or when conducting medication management reviews,’ she explained.

‘We also have the knowledge, skills and capacity to work with patients to identify their specific barriers to safe and appropriate medicine use and address them.’

This could involve providing behavioural interventions, such as:

• using dose administration aids
• simplifying medicine regimens
• setting alarms to remind patients to take medicines, and 
• motivational interviewing and regular follow-ups.

But, as no single intervention is likely to help everyone, Dr Cross said the most important thing was to take the time to understand your patient.

‘Identify their concerns or challenges with taking medicines, assess their ability to manage medicines (including health literacy, cognitive function, dexterity, etc) and identify what interventions for improving medicine-taking ability and adherence will work best for them,’ she said.

‘Non-adherence is multifaceted. It is essential that interventions are patient-centred and that they target specific barriers to non-adherence or poor medication-taking ability that the individual patient is experiencing.’

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